Skip directly to search Skip directly to A to Z list Skip directly to navigation Skip directly to page options Skip directly to site content

AFIX Site Visit Questionnaire

General Notes

Questionnaire may be filled out prior to the AFIX visit or during the visit. The assessor, along with the provider, should select 2-3 strategies to incorporate into the QI plan for implementation and follow-up

  • If questionnaire is filled out during the visit and using CoCASA, the provider’s demographic information should be entered in the provider set-up tab
  • If questionnaire is filled out during the visit and using AFIX online tool, the provider’s demographic information should be entered in the General Site Visit Information tab
  • If questionnaire is mailed out prior to the AFIX visit, the following provider demographic questions should be added to the top:
    • Assessment date:
    • Assessment name:
    • Assessor’s name:
    • Provider site name:
    • Provider address:
    • Contact person:
    • Telephone/fax:
    • E-mail:
    • VFC pin number:
    • Type of medical records the provider uses: Electronic (type); OR Paper
    • Method of reporting to the IIS:


Strategies to Improve the Quality of Immunization Services

  1. Do you have a reminder/recall process in place for pediatric/adolescent patients? (y/n)
  2. Do you offer walk-in or immunization only visits? (y/n)
  3. Do you routinely measure your clinic’s pediatric/adolescent immunization coverage levels and share the results with your staff? (y/n)
  4. Do you schedule the next vaccination visit before the patients/parents leave the office? (y/n)
  5. Do you contact patient/parents within 3-5 days when a "well child" or “immunization only” visit is a "no show" and reschedule it for as soon as possible? (y/n)
  6. Do you have a system in place to schedule wellness visits for patients at 11-12 years of age? (y/n)
  7. Do you have an immunization champion at this practice that focuses on QI measures, reducing barriers, and improving coverage levels? (y/n)
  8. Do you regularly document vaccine refusals and reasons for refusals (parent choosing to delay, parent has vaccine safety concern, medical contraindication, etc.)? (y/n)
 Top of Page

Strategies to Decrease Missed Opportunities

  1. Does your immunization staff educate parents about immunizations and the diseases they prevent, even when the parents refuse to immunize? (y/n)
  2. Do you have immunization information resources to help answer questions from patients/parents? (y/n)
  3. Is your immunization staff knowledgeable and comfortable with current ACIP recommendations, including minimum intervals, contraindications, etc.? (y/n)
  4. Do you train front desk/scheduling staff so they know when it’s appropriate to schedule immunization appointments? (y/n)
  5. Do you have standing orders for registered nurses, physician assistants, and medical assistants to identify opportunities to administer all recommended pediatric/adolescent vaccines? (y/n)
  6. Is your immunization staff knowledgeable and comfortable with administering all recommended vaccinations to patients at every visit? (y/n)


Strategies to Improve Completeness and Accuracy of Immunization Information in the IIS

  1. Does your staff report all immunizations you administer at your clinic (or practice) to your state/city IIS? (y/n)
  2. Does your staff report immunizations previously administered to your patients by other providers to the IIS (e.g., official shot record, other IIS report, copy of medical record)? (y/n)
  3. Do you inactivate patients in the IIS who are no longer seen by your practice? (y/n)
  4. Do you use your IIS to determine which immunizations are due for each patient at every visit? (y/n)
 Top of Page